Exploring Radiologists’ Burnout in the COVID-19 Era: A Narrative Review

Since its beginning in March 2020, the COVID-19 pandemic has claimed an exceptionally high number of victims and brought significant disruption to the personal and professional lives of millions of people worldwide. Among medical specialists, radiologists have found themselves at the forefront of the crisis due to the pivotal role of imaging in the diagnostic and interventional management of COVID-19 pneumonia and its complications. Because of the disruptive changes related to the COVID-19 outbreak, a proportion of radiologists have faced burnout to several degrees, resulting in detrimental effects on their working activities and overall wellbeing. This paper aims to provide an overview of the literature exploring the issue of radiologists’ burnout in the COVID-19 era.


Introduction
Burnout is the experience of emotional exhaustion, depersonalization, and reduced personal accomplishment emerging as a prolonged response to chronic interpersonal stressors on the job [1]. It can affect the social and personal wellbeing of the professionals involved, resulting in psychological consequences (such as depression and a higher risk of suicide) that may have a negative impact on their quality of life, and on a larger scale, lead to reduced productivity and inflated healthcare costs [2][3][4].
The 2020 Medscape National Physician Burnout and Suicide Report revealed that 46% of radiologists are burned out, as compared with 42% of all physicians [5]. Triggers of stress and burnout for radiologists include heavier workload and complexity of cases, work-life imbalance, dysfunctional workplace dynamics, computer failure and consequently lack of control of their work, discontinuities in workflow (due, e.g., to ambient sounds from A systematic literature search was carried out to analyze radiologists' burnout in terms of causes, incidence, and possible remedies in the COVID-19 era. We searched the PubMed (https://pubmed.ncbi.nlm.nih.gov (accessed on 8 December 2022)) and Scopus (https: //www.scopus.com (accessed on 8 December 2022)) databases by using a combination of the following search terms: (("stress in radiologist" OR "burnout in radiologist" OR "demotivation in radiologist") AND ("stress in radiology" OR "burnout in radiology" OR "demotivation in radiology")). The search period ranged from March 2020 to December 2022, and the search was performed on 8 December 2022. Only articles published in English language were included.
To improve the quality of our inclusion criteria, our analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [62].

Results
Two reviewers (M.G., L.F.) manually screened all articles retrieved (n = 182) by title and abstract, removed all duplicate records (n = 5) and if potentially eligible, their full text was reviewed. Exclusion criteria were as follows: (1) articles reporting data collection carried out before 2020 (n = 10); (2) review, editorial, and commentary articles (n = 15); (3) no access to the article's full text (n = 8).
A total of 122 studies were excluded due to having irrelevant titles and abstracts, and the remaining ones underwent a more thorough analysis. Finally, 22 articles were singled out and divided into the following categories: (1) stress emerged during the COVID-19 outbreak (n = 10), (2) stress unrelated to the COVID-19 outbreak (n = 2), and (3) strategies to enact as possible remedies to burnout (n = 10) (Figure 1).
Two reviewers (M.G., L.F.) manually screened all articles retrieved (n = 182) by title and abstract, removed all duplicate records (n = 5) and if potentially eligible, their full text was reviewed. Exclusion criteria were as follows: 1) articles reporting data collection carried out before 2020 (n = 10); 2) review, editorial, and commentary articles (n = 15); 3) no access to the article's full text (n = 8).
A total of 122 studies were excluded due to having irrelevant titles and abstracts, and the remaining ones underwent a more thorough analysis. Finally, 22 articles were singled out and divided into the following categories: (1) stress emerged during the COVID-19 outbreak (n = 10), (2) stress unrelated to the COVID-19 outbreak (n = 2), and (3) strategies to enact as possible remedies to burnout (n = 10) (Figure 1). The articles analyzed report the findings from surveys and the remaining articles are summarized in Table 1 and Table 2, respectively. The articles analyzed report the findings from surveys and the remaining articles are summarized in Tables 1 and 2, respectively. Response rate 21% 69% of respondents felt more isolated from a lack of regular interaction with colleagues 53% of respondents indicated that it is challenging to work remotely while overseeing home schooling for children In comparison to men, women reported overall higher work-related stress and anxiety (p = 0.02), higher feelings of guilt from radiology staff (i.e., technologists and nurses) being more exposed to COVID-19 (p = 0.02) and higher levels of stress providing for dependents (p = 0.04) The COVID-19 pandemic induced practice alterations and high rates of self-reported anxiety in interventional radiology Female gender, increased call coverage, and lack of adequate or timely departmental adjustments were associated with increased anxiety levels Table 2. Articles analyzed not based on surveys.

Authors [Reference Number]
Year Objective Aggarwal et al. [72] 2021 To discuss several strategies for mitigating high volumes, including abbreviated MRI protocols, 24/7 radiologist coverage, reading room assistants, and other strategies to tackle radiologist burnout Belfi et al. [73] 2022 To investigate the process of storytelling as a self-care practice for radiologists Brown et al. [74] 2021 To introduce wholeness, rather than wellness, to address the symptoms of burnout To focus radiologist as member of health care teams, rather than an individual, as a solution to the problem Buch et al. [75] 2021 To implement a wellness program in an academic radiology department to prevent burnout and to assess initial outcomes, with special focus on the challenges related to the COVID-19 pandemic

Discussion
To recognize and address burnout, physicians should be aware of its manifestations and demographic variability. A contribution to burnout may derive from the so-called imposter phenomenon, which has a high rate of prevalence in medical professionals and refers to a feeling of inadequacy and self-doubt due to the inability to internalize and accept success and skill. Deshmukh et al. [82] investigated the occurrence of burnout in radiologists and reported a statistically significant correlation (p = 0.024) between burnout and the imposter phenomenon, with 83% of surveyed clinical radiology faculty reporting feelings of imposter phenomenon during their career. Possible explanations include the rapid development of technologies in the field, the quick pace of daily workflow, and the lack of positive reinforcement via patient interactions.
During the COVID-19 pandemic, work-related stress ramped up because of mandatory changes [48,[83][84][85][86][87][88][89][90][91][92][93][94]. Several surveys [61,64,65,67,68,70,71,95] conducted during the COVID-19 outbreak in different countries have revealed a sensible impact of it on radiologists' life in terms of anxiety, fear of spreading the infection, difficulty sourcing PPE, shifts in workload due to an increase in emergency procedures, and feeling that the crisis had affected their family relationships and damaged their own and their colleagues' professional activity. In a survey conducted among North American pediatric radiologists by Ayyala et al. [63], 69% of respondents endorsed feeling more isolated from a lack of regular interaction with colleagues due to an increase in remote working. A balance between work and personal life was a critical issue (with 53% of respondents indicating that it is challenging to work remotely while overseeing home schooling for children), resulting in conflicting situations between at-work and outside-work duties.
Furthermore, concerns were expressed by trainees and educators regarding the effectiveness of education programs limited by social distancing, lack of regular clinical activities, difficulty changing residents' rotations or postponement of core examinations [61,64]. However, Huang et al. [66] showed that compared to nonradiologists, radiology staff reported lower mean scores of anxiety (4.0 vs. 4.9, p = 0.035) and burnout (1.9 vs. 2.1, p = 0.002). Moreover, among radiology staff, anxiety and burnout were associated with longer than usual working hours (p < 0.01), and higher job dedication was associated with lower anxiety (p < 0.01). Such findings could be related to sufficient reserves of PPE, rapid testing, and ready access to up-to-date information, but also to stronger job dedication and teamwork.
Recent papers have revealed that women are more susceptible to burnout than men, particularly in relation to the COVID-19 outbreak [79,80,96], also due to being subjected to more stressors related to familial duties. Huang et al. [67] found that the resilience of female medical staff in radiology departments during the COVID-19 outbreak was significantly lower than that of male medical staff. In a study by Milch et al. involving breast radiologists [69], psychological distress was reported to be highest among females, younger professionals, and those with greater pandemic-specific childcare needs and financial losses, threatening to exacerbate existing gender disparities in radiology. More generally, Ayyala et al. [63] reported that compared to men, female radiologists suffered from higher work-related stress and anxiety (p = 0.02), greater feelings of guilt from radiology technologists and nurses being more exposed to COVID-19 (p = 0.02), and higher levels of stress providing for dependents (p = 0.04). Conversely, in the Italian nationwide survey by Coppola et al., women from areas more severely hit by the COVID-19 crisis were less susceptible to feeling like living in slow motion than those from other areas, possibly related to a greater sense of control in workplaces more directly affected by the crisis, which could foster engagement and help avoid burnout [61,97,98].
The COVID-19 outbreak has unraveled the advantages of remote working, but also its disadvantages in terms of isolation, especially for pediatric radiologists, whose professional activity entails more patient interaction than other radiology subspecialties [63]. In the last years, radiologists have assumed a more active role in patient care by taking part in team decision-making, thus clarifying the diagnostic strategy and refining the therapeutic decisions of clinician members [99,100]. In keeping with Brown et al. [74], the distancing requirements caused by the COVID-19 pandemic have emphasized the value of interdisciplinary collaboration, suggesting that cultivating relationships with patients and colleagues could be key to fighting off burnout through a "wholeness" (rather than personal "wellness") approach.
The causes of burnout are probably multifactorial, and therefore it is unlikely that there can be a single remedy. General strategies to combat these issues may include education on existing evidence-based practice guidelines, and utilization of computerbased clinical decision support systems to perform appropriate radiological procedures, avoid redundant imaging and streamline imaging protocols. Furthermore, excessive workload and understaffing in healthcare environments can add to work-related stressors and possibly lead to burnout, whereas maintaining an adequate supply of physicians is vital to a well-functioning healthcare system. Fostering innovation in radiology departments (such as the widespread adoption of radiological structured reporting, the use of validated AI systems to assist radiologists' activity, the implementation of optimal ergonomics, and the constructive use of social media) can also play a role in preventing burnout by optimizing workflow and improving overall work quality [77,78,81,.
Another approach to burnout could be improving the mental status of radiologists by building resilience and practicing mindfulness [72]. Mindfulness has its roots in Buddhism, in which practitioners pay attention to each moment with openness and acceptance without judgment and turn their minds away from the stress of daily life [76,137]. Buch et al. [75] illustrated the results of the implementation of a faculty wellness program in an academic radiology department before the COVID-19 pandemic and evaluated the change in such initiatives following the pandemic. In the pre-COVID-19 era, their program focused on improving efficiency, limiting disruptions, improving reading rooms and ergonomics, creating a more efficient workflow, and opportunities for social interaction and team building. After the onset of the COVID-19 pandemic, radiologists requested more initiatives focused on wellbeing, emotional health, mindfulness, and personal access to mental healthcare. From this viewpoint, according to Fishman et al. [76], coaching is an emerging and promising approach to address the burnout epidemic affecting radiologists. Coaching can be defined as "partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential". Professional coaches help clients, who already possess the skills needed to overcome the challenge they face, to navigate their professional and personal journeys through better steering of talents, resources, and desires [138,139].
Belfi et al. [73] reported a positive impact of storytelling on radiologists' perceived sense of wellbeing, shifting their sense of empathy and connectedness to others during the COVID. Nineteen Association of University Radiologists (AUR) members were selected for participation in Storytelling Geek Week, a virtual workshop that took place over five days in November 2020. Participants' current state of wellbeing was significantly increased between the pre-and post-course surveys (p = 0.017), and respondents reported shifts in their sense of empathy and connectedness to others, suggesting that storytelling may help mitigate burnout and build community during challenging times.

Conclusions
Burnout is a complex phenomenon that affects radiologists as members of the medical community and has seen a surge during the COVID-19 outbreak due to its dramatic impact on public health, extending beyond working environments to the family and personal lives of healthcare professionals. Radiologists have worked in the frontline of healthcare systems during the COVID-19 pandemic, experiencing a disruption in their work activities, especially during the first wave of the crisis. This has resulted in an increased vulnerability to burnout, and in several cases has exacerbated criticalities in radiology workplaces hailing back to the pre-COVID-19 era, leading to some manifestations that are specific to the radiologist's profession. In line with Kruskal et al. [139], organizations and leaders will need to reprioritize efforts to build high-functioning cohesive teams, implement peer-support practices, and support posttraumatic growth, while optimizing meaning in work. A multipronged approach that involves optimizing resources, improving workload efficiency, adapting technology-based solutions, and promoting wellbeing (both as individuals and among colleagues working in the same environment with the goal of promoting patients' health) could be key to preventing the risk of burnout while improving job quality, efficiency, and overall satisfaction.